House health care vote: Decoding the smoke signals

Speaker of the House Paul Ryan, R-Wis., holds up a copy of the American Health Care Act during a news conference with House Majority Leader Kevin McCarthy, R-Calif., left, and House Energy and Commerce Committee Chairman Greg Walden, R-Ore. (Photo by Chip Somodevilla/Getty Images)

WASHINGTON, D.C. — The House of Representatives on Thursday is scheduled to vote on the American Health Care Act, the Republican legislation intended to “repeal and replace” the Affordable Care Act.

The outcome is about as easy to predict as the November elections.

The only thing that is clear is that this is a very important vote for the young Trump presidency and for scores of millions of Americans whose medical care and personal finances could be swiftly altered.

President Trump made the trek down Pennsylvania Avenue on Tuesday to twist arms and do the deal. The vote count, according to both sides, is close and in flux. No Democrats are expected to vote for the AHCA, which means that the GOP can lose only 22 of its own members.

With all that in mind, here are some variables and mysteries to pay attention to in the pre-game spin and post-game analysis.

Will the vote even happen on Thursday? Not necessarily. No matter what they say, it is common for party leaders to delay big votes if they think more time will win them more votes. Of course, the minute they think they have the votes, the rush is on. If the whip count is fatal, the bosses usually want to get the bad news over with quickly. Recent polling shows that voters like Trumpcare less the more they learn about it and that may mitigate against any delays.

How free is the Freedom Caucus? The House GOP’s right wing and its fraternity, the Freedom Caucus, haven’t fudged in the least: They hate the Ryan-Trump bill and call it Obamacare 2.0 or Obamacare-lite. Almost all of them come from safe Republican districts and in recent years have bucked party leadership plenty of times in the name of ideological purity. Just ask former Speaker John Boehner about that. The Trump Factor, however, is the wildest of wild cards. Trump has scared Republican foes of all stripes into silence ever since he grabbed the nomination. Members do not want to be attacked by name in Trump tweets. Many believe Trump is far more popular in their home districts than any ideology or set of positions. Some in the Freedom Caucus will stick to their philosophic guns. Others will make complicated political calculations. Uncertainty ensues.

Does the GOP Big Tent have two or three poles? There’s the right wing pole, the Ryan pole of party authority and then the moderates poll a little over to the left. Or is there? Will there be House Republicans who buck Ryan and Trump because they think Trumpcare goes too far and risks taking insurance away from too many people. If there are, that could compensate for some Freedom Caucus “yes” votes. That is a big “if” as the vote approaches.

Did the grassroots protests matter? Republicans who couldn’t avoid them during their last recess were besieged by protests and mobilized voters. They came from the right and left, but the overwhelming message was about fear of losing insurance coverage. Congressional offices have been lobbied hard by grassroots activism and social media pressure. In the end, will it add up to a lot of noise or a newly active and influential citizen activism?

How much do interest groups matter in Trump’s Washington? The money at stake in this legislation is huge, obviously. But the lobbying dynamic is very different than in the past. Drew Altman, the head of the Kaiser Family Foundation, thinks this will be the first big health care bill where pure partisanship will be a more decisive factor than special interest pressure dynamics. That said, the groups lined up against the AHCA are mighty and varied: the conservative Heritage Action group, the American Medical Association, AARP, the American Hospital Association and a cadre of Republican governors.

The House GOP vs. Senate GOP: Frenemies? The Ryan-Trump bill can only afford to lose two votes in the Senate and still pass. The ideological dynamic is different from the House because there are more GOP moderates than archconservatives inclined to kill the bill. There are at least 10 arms in the Upper Body that will have to be seriously twisted or Trumped. Some already are saying Trumpcare is DOA in the Senate. So even if the ACHA passes the House, it will still face a long strange trip.